Paul van Heeswyk

A CHILD PSYCHOTHERAPIST IN PRIMARY MENTAL HEALTH

This paper outlines the authors application of psychodynamic thinking and approaches to brief therapeutic work with children, adolescents and their families in community mental health settings. It is the authors belief that systemic and narrative therapy insights and techniques combine well with psychoanalysis in the assessment and treatment of many concerns felt and expressed by parents and young people. The therapists tasks are to listen empathically to clients who are in distress and to explore the clients beliefs about the origins of their problems, as well as their previously attempted solutions. In proceeding at the familys pace, opportunities arise for facilitating more effective ways of resolving conflict. Clients are often more free than they realise to change their interpretation of their experience, and this has important consequences for the maintenance and solution of problems. Brief therapy seeks to remind clients of their strengths and resources and to share ways to encourage clients to resume effective ways of learning about themselves. Keywords child psychotherapy; primary care; psychodynamic; narrative; systemic; brief interventions

Introduction: timely services

The real voyage of discovery consists, not in seeking new landscapes, but in having new eyes. (Marcel Proust) The National Service Framework for Children, Young People and Maternity Services establishes 11 standards for promoting the health and well-being of young people, the ninth of which covers mental health needs. This standard requires that all children and young people should have access to timely, integrated, high quality, multidisciplinary mental health services. A marker of good practice is when child and adolescent mental health (CAMH) professionals provide a balance of direct and indirect services and are flexible where children, young people and families are seen. An important component of indirect services will be consultation, training and support to all first line services who have contact with young people and their families, in health, education, social work and other community settings. Clinicians recognise that the provision of timely services requires the quickest possible response to people in need. This is not just a matter of dutiful compliance
Journal of Social Work Practice Vol. 19, No. 3, November 2005, pp. 251261 ISSN 0265-0533 print/ISSN 1465-3885 online 2005 GAPS http://www.tandf.co.uk/journals DOI: 10.1080/02650530500291047

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with what can feel like an excess of targets and recording demands, in a world where services are continually being reviewed, authorised or deleted. We all know how painful the worries and concerns about their children are for parents who often feel isolated in the absence of support from extended family and local neighbourhood or community. As CAMH professionals, we feel better about ourselves and our work when we do not have to make families wait for our help. We also know that a rapid response, delivered close to the moment at which families recognise the need for help, can prove especially effective. However, in the finite world of human resources within CAMH Services (CAMHS), a corollary of improved accessibility and rapid response is the requirement for services to be brief or time-limited. Where such interventions are appropriate and well-matched, so much, of course, the better. But there remains the concern that the impact of financial and other pressures can lead to the provision of services that are possible and available, rather than those that are needed. This can seriously undermine the professional morale of clinicians who may feel themselves to be confronted by an apparent obsession with quantity and statistics at the expense of quality of work. I qualified as a child psychotherapist in 1981 and have worked for the last five years as a Primary Mental Health Worker in a Health Centre, alongside general practitioners (family doctors), health visitors, school nurses, district nurses and other colleagues in NHS professions. The policy within our particular CAMH Directorate, in the spirit of the National Service Framework, is for experienced professionals from social work, nursing, family therapy, clinical psychology and child psychotherapy to practise as Primary Mental Health Workers at Tier 2, providing a specialist individual professional service to families, as well as consultation and training to colleagues in primary care. In addition, Primary Mental Health Workers are members of the specialised multi-disciplinary Tier 3 service which is offered for more severe, complex or persistent disorders. In this paper, I will outline my specific contribution as a child psychotherapist, in terms of thinking and approach, to the field of primary mental health.

Principles for making therapy shorter

Child psychotherapists have always worked in community settings and have recognised the need for brief interventions in their work with young people and their families. This sometimes comes as a surprise to other mental health professionals who refer to the long training of child psychotherapists, the minimum of five years of personal analysis, and the core commitment to intensive and long-term individual treatment of clients that is required for qualification. Clearly, much of the therapy carried out by child psychotherapists at Tier 3 will be open-ended and of longer duration, a task for which our training uniquely qualifies us, but an important aspect of the lone practitioner role in primary mental health is the assessment of suitable treatment for children and young people who present with emotional and psychological difficulties. In particular, one question that continually arises in community child mental health settings is whether a brief therapy approach is appropriate to the needs of a presenting family. I, myself, share the view of the Italian

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family therapist and trainer Mario Andolphi, who was once apparently heard to say at a workshop: to make shorter the therapy, first make longer the training (quoted in Ecker & Hully, 1996). Moshe Talmon (1990) reminds us that Sigmund Freud, the founder of psychoanalysis, (probably the longest form of therapy), once treated a patient known as Katharina in one session whilst on vacation and that Freud later claimed to have cured the composer Gustav Mahler of impotence during a single long walk in the woods! My own interest in psychodynamic approaches to brief therapy began with the work in the 1920s of two close colleagues of Freud Ferenczi and Rank who were concerned that psychoanalysis had become too didactic and cerebral. These two analysts sought to shorten the treatment (which could often appear interminable) through an emphasis on a more experiential encounter of doctor and patient. I am often reminded in my clinical work of some observations of Otto Rank, which, with a few changes of terminology and emphasis, could have contemporary relevance and warnings: While the parents are inclined to overlook the part played by their own conflicts in the childs problems, or to completely deny it, the child on the other hand is more inclined to feel itself responsible for the parents difficulties. And actually this feeling of the child is to a certain extent justified. The child brings a new element into the relation of the parents one to another, and this element is not always, or is not completely, a harmonious one. The fact that the child seems to feel this more than the parents is obviously connected with its whole attitude to the world of reality. The child inclines too much to identification, which he only gradually gives up at the adult stage of the so-called adjustment to reality if he ever gives it up at all. In contrast to this, the adult is very much inclined to projection, which is to say is the price at which he purchases his adjustment. the child inclines altogether to introversion guilt feelings can more easily be unburdened if he is permitted to project his conflicts onto the parents the child has to learn to allow himself to make the parents responsible for certain difficulties, instead of looking for the fault exclusively within himself which leads to the feelings of guilt and inferiority such an attitude on the childs part tempts pedagogues and parents to look with the child for the cause of all evil in the childs own emotional life (Otto Rank, 1927) As absolutely dependent infants, we are born with the imprinted urgent need to form close attachments to our carers. The inherited memory of the species is that children who bond with their parents will be looked after and will live, whereas those that do not will be abandoned and will die. Our sensitivity to the actions and responses of our parents towards us is therefore a felt matter of life and death that leaves us with a propensity for fundamental anxieties in terms of whether we are loved or not. Such anxieties can leave a residue in terms of templates for future relationships: If my mother does not love me, I am unlovable, in and of myself, and for all time. Abusers, we know, typically project guilt and may exploit a tendency in vulnerable children to believe that their bad treatment is in fact deserved punishment. But as Rank points out, there can be an unnerving continuum here. In terms of the

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family life cycle, the birth of a child to the couple can constitute a normative crisis, unleashing all sorts of conflict in the parents. Partners become parents and the twosome must adjust to accommodating a third member, with the possible reemergence of early feelings of rivalry and exclusion. Similarly, in Ranks anticipation of Winnicotts work on the anti-social tendency, environmental failure must sometimes be acknowledged and repaired before a childs atrophied development can resume its course. However, Gregory Bateson states an important principle for individual therapists to take into account. In the field of psychiatry, the family is a cybernetic system and when systemic pathology occurs, the members blame each other, or sometimes themselves. But the truth of the matter is that both these alternatives are fundamentally arrogant. Either alternative assumes that the individual human being has total power over the system of which he or she is a part no part of such an internally interactive system can have unilateral control over the remainder or over any other part. The mental characteristics are inherent or immanent in the ensemble as a whole. (Bateson, 1972). This systemic principle has helpful and liberating implications for working with the mental health needs of young people in challenging the scapegoating or pathologising of individuals. As such, it forms part of an approach that underpins the work of family therapists. For myself as a child psychotherapist, the work of Winnicott is similarly fundamental.

Interventions based on theories of emotional development

Winnicott was a paediatrician who later trained as a psychoanalyst. For these reasons, probably, he believed that one must have in ones bones a theory of the emotional development of the child and the relationship of the child to the environmental factors (Winnicott, 1971). The parents are the first environment and their task is to adapt actively to the needs of the infant, but it is clear, of course, that children need a different and evolving quality of relationship to their carers at each stage of their development to sustain growth. A Winnicottian-based approach seeks out and highlights the strengths and resources of both children and parents and combines this with a developmental theory that facilitates the identification of the particular goal for each stage of development and the kinds of interaction that will facilitate its successful attainment.

Case example: John

John is eight and has begun stealing from his family. He also has episodes of encopresis. I sense from the anxious looks in my direction from his worried but clearly devoted parents that they are concerned that he may have been abused. They seem to want me to get to the bottom of this, so to speak, seemingly, if our methods of attempting to communicate with each other are any guide, by some form

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of mind-reading or other divination. Fortunately, as it turns out, my easily assumed air of incompetence and incomprehension forces mother to ask her son directly the question she has hitherto felt too frightened to ask. I am now witness to a moving dialogue which convinces and reassures both parents and myself that no one has ever physically harmed this boy. Parental relief opens up further sharing. Mother tells her son how, when John was a few months old, she lost her own mother in a fatal road accident, a family story that clearly John already knew. However, mother now feels that in retrospect, she was certainly traumatised by this sudden bereavement and she wants to let John know that he must have felt that he suddenly lost his mother too. Father regrets that he did not help out more at home, preoccupied as he was with work commitments. One year later, the first of Johns three siblings was born. The parents have linked their sons stealing with his loss of something he was entitled to assume was his by right, a certain and continuing quality of care and attention from his mother and father. The family ask to return in two weeks when I learn that there has been little change in Johns behaviour. We look together at how the parents have been responding to Johns stealing (there has been another incident) and it becomes clear that their attempts to encourage John to earn his pocket money through good behaviour are not working. The main problem in the family, the parents agree, is Johns stealing. In the spirit of their understanding of the origins of this, they agree to give John an appropriate sum of pocket money every week, irrespective of his behaviour and, more importantly perhaps, to ensure they spend some special time with him on a regular basis, sharing with him an activity he really likes to do that is chosen by him. I feel the parents have symbolically returned to and addressed an infants missing relational experience and my wish now is for us to engage with the undoubted strengths and capacities of the eight year old before us. All four of us work out together a version of the honesty test ritual (Durrant & Coles, 1991; Epston, 1989) in which Johns parents will inform him of a place in the house where they will leave a sum of money unattended, after they have heard from him some methods he has successfully used to stop himself stealing in the past and have talked through with him some strategies they have themselves found helpful in dealing with temptation. John will then let them know next day, on a scale of 1 to 10, how difficult it was to resist the temptation and which particular strategy he found most useful. Parents and child leave with a spring in their step, and I ask John if he might think about sharing the plan with his grandfather, who, he had told me previously, was the person outside of the immediate family who was most worried about him. In listening to some of the concerns parents bring to child mental health settings, I sometimes think to myself that I have often had similar or more severe concerns about myself as a parent or partner, and likewise equally unsettling worries about my children, and yet I did not seem to feel the need to seek professional support. As I reflect on this, it does not seem to me that this is my professional pride or personal denial in operation, since I have no difficulty in talking about these matters to anyone I can get to give me attention. Again, Winnicott can be helpful here in putting matters in perspective. We are poor indeed if we are only sane he once famously remarked and true neurosis is not necessarily an illness we should think of it as a tribute to

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the fact that life is difficult. Again, even when our patients do not get cured they are grateful to us for seeing them as they are.

Solution or reawakening?
Through psycho-education and normalisation, therapists in primary mental health can sometimes alleviate parental concerns about what they may be identifying as worrying behaviours in their children. It is a measure of how isolated families can be in contemporary urban areas that they do not realise that many children struggle in very similar ways with particular developmental challenges that lead to no serious long term consequences for their emotional health. But more than this, childrens problems, struggles and conflicts can even be seen as necessary and inevitable for growth. At each developmental stage, children have to negotiate optimal personal and environmental mismatches, the complex interactions between their psychological functioning and the values of their families, peers, schools and communities. This can lead to disequilibrium and new problems . The therapist needs to be sensitive to the effects of the childs own adaptation to his developmental struggles on other family members and how family members, in turn, respond to the child (Selekman, 1997). There is another important issue here as well, an issue that those clinicians working within a brief or solution focused approach continually highlight. A major difficulty with outcome studies in the area of mental health is that the successful case at discharge may not be a cure in the sense of the elimination of a problem or symptom, but may instead be the reawakening in the family of the belief that they have now (and probably always have had in other areas of their life at least), the tools and resources to deal with problems as they arise, even if life may be hard sometimes and solutions slower to take effect than they would like. In this age of rapid change, demands for instant solutions become increasingly more insistent (as five minutes spent watching television commercials will confirm). However, we humans are a problem-solving species and if, inadvertently, in the course of our work, we take the recognition of this capacity away from our clients then they leave with less than they came. The task of the therapist in primary mental health is not to find out what is wrong with the clients and then tell them, but to share with the clients ways to enable them to resume effective ways of learning about themselves. The work sets in motion or re-starts a process, in the hope that this will be selfmaintaining. For example, all therapists presumably share a belief that humans create much of the meaning they attribute to the events and relationships they perceive in the world around them. Narrative therapists maintain that the ways we perceive ourselves and the world are organised through the stories we tell ourselves, and that this is the inevitable accompaniment of our interactions with others. Moreover, because stories imply certain futures, they inevitably exert powerful influences on our present thinking and behaviour. In constructivist approaches, the emphasis is on recognising that people are active in the creation of their experiential reality, even though they usually feel that this

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inner world of meaning is operated by some remote control device in the hands of somebody (close relatives) or something (the culture) else. This is the often reported sense of feeling like a helpless passer-by in ones own life. As a child psychotherapist, I am inclined to feel that the reason people are unaware of their role in assembling their model of reality and of the extent to which they choose to give meaning to events in their lives, is that much of this process is carried out unconsciously. Nevertheless, even though there may always be some difference in terms of the extent to which people can or should reinvent their subjective picture of the capacities, responsibilities and relationships of themselves and others, I share with brief therapists the conviction that people are freer than they realise to make changes in how they view and interpret their reality, and that this has important consequences for the ways problems are created and solved. This is not to say, of course, that all personal suffering can or should be eliminated by reframing, or by authoring another story. The grief and sadness of loss, or the rage at frustrating obstacles or unfair and abusive treatment, are appropriate responses, however unpleasant for the sufferers concerned or those around them. These responses might only be considered symptomatic if expressed in self-endangering behaviour, displaced onto undeserving targets, or if appearing to be stuck and unchanging over a protracted period of time. A common criticism of some solution-focused approaches to brief therapy, however, is that families can feel that their worries are not taken seriously and that they have not been listened to, if they are not given sufficient opportunity to talk about their problem. Worried parents and young people should not be rushed and the therapist, of course, also needs time to gain an understanding of the steps the family have taken to secure an appointment with the primary mental health service. Did the parents and children feel they were unclear why they were referred by a concerned professional from another agency, or were there specific triggers that led the family themselves to a decision to seek help? It is important to take time to listen to how each family member views the problem and to explore their thoughts about its causes and origins, as well as attempting to ascertain what the consequences of the problem have been for each individual. We know that a problem shared is a problem halved, and a problem well-defined is half solved. Thus, if my maths is right, we could at this stage already be down, problem wise, to quarter size. But more importantly, the statement of the problem will greatly inform the assessment. Furthermore, the therapists hurry to move into solution-talk may mean that an opportunity is missed to help those families who have not found effective ways to resolve conflict and who are over-reliant on repressive or scapegoating methods of managing difference. Although the key transformational insight in narrative and constructivist therapies is the recognition that the person is not the problem, it is often the case that families will arrive for a first meeting with the firm belief that one of their number is indeed the problem. Generally, the parents, and sometimes the referred young person as well, will see the problem as undesirable and will feel powerless to stop or control it. Family members may also take the existence of the problem to prove something very shameful about themselves. The parents may feel they are inadequate or failures, the child may just feel bad and guilt-ridden. Through careful listening it becomes possible at some points to check out whether the familys account of their difficulty

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comprises what narrative therapists call thin or totalising descriptions. In other words, is there a pattern in which only a limited number of events in the childs life are selected and given weight, when others which contradict the dominant story are ignored and discounted? Often, a childs whole identity may succumb to a totalising description: He is aggressive, a bad child; He is a bully, etc. For the child or young person, the multi-faceted experience of self may become narrowed and circumscribed as he or she fuses or becomes one (identifies) with a single set of experiences that is felt to offer a complete and final definition of self. Thus, an important part of the assessment in primary mental health consists of the attempt to see what the family does when encouraged to look for and access alternative stories about their child that contradict the problem-saturated one. To some extent, this may take the form of a suggestion that the parents move out of their habitual and emotionally-charged immediate reactions to their childs behaviour and become, for a period of time, interested observers and diarists. For many parents, this offers the possibility not only of seeing with new eyes a fuller picture of their child and themselves, but also of regaining a sense of perspective and compassion. The therapist attempts to see whether whatever is said or believed by the family could be looked at from other points of view, and could, thereby, lose its absolute quality. One advantage of keeping a diary is that you become aware with reassuring clarity of the changes which you constantly suffer and which in a general way are naturally believed, surmised, and admitted by you, but which youll unconsciously deny when it comes to the point of gaining hope or peace from such an admission. In the diary you find proof that in situations which today would seem unbearable, you lived, looked around and wrote down observations, that this right hand moved then as it does today, when we may be wiser because we are able to look back upon our former condition, and for that very reason have got to admit the courage of our earlier striving in which we persisted even in sheer ignorance. (Franz Kafka, 1948) An important presupposition of this kind of intervention that seeks to broaden observational powers and parental perspective is that even if one member of the family is exhibiting worrying behaviour, it may be that the problem in fact is located in the way the family operates as a group. If new information, in the form of changed parental beliefs as a consequence of new perspectives, is introduced, there is the potential for change in the patterns of interaction and communication within the family. In other words, if obsolete parental beliefs and interactions with the child can be changed, this may lead to changes in the child. But for this to become possible, the parents observation of their child, and the childs self-observations, must be in relation to a problem that can be solved. Oppositional Defiant Disorder, for example, is a diagnostic category but not a solvable problem for a family in therapy. However, a young person who behaves in a challenging way, swears and refuses to comply with parental requests and rules, presents us with an operational problem that is in

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principle capable of being solved. Questions to the child and family need to be framed in language that suggests a way of looking at problems in terms of events or behaviours that can be measured and observed and that will allow clear feedback in terms of whether change is occurring. Does your child always speak in an abusive manner to you, or does she sometimes speak in an acceptable way? Even when your daughter is behaving in ways you do not like, are there times when this is less troublesome or severe? To the child: Do you know when you are going to respond in a rude way to your parents? Are there times when you do what is asked of you without complaint? What is different about those times? Where such interventions and approaches do not seem to lead to change, important information has been gathered in terms of the assessment. Perhaps the problem is not simply the consequence of outmoded beliefs or dominant oppressive stories. Perhaps it is not the case that the repetition and intensification of the same parental attempts at solutions is maintaining the symptom or difficulty. Child psychotherapists are used to thinking of the possibility that a childs socalled symptom, however distressing to the child himself, may constitute a solution to a problem that to the child seems worse. In other words, although consciously the child may express the desire for the symptom to stop, he may at times feel the problem to be necessary and must therefore continue to produce it. Some aspects of this kind of issue will be familiar to all CAMHS practitioners, especially where problematic behaviour clearly seems to serve a function in the family. For example, it is common for children to attract attention to themselves by employing worrying behaviours or symptoms if they feel that their warring parents will only stop fighting when they can unite in their shared concern for their child. Such a strategy may be implemented by the child with varying degrees of consciousness but if the marital problem is missed in the assessment then no attempt to persuade the child to give up the problem will be likely to succeed. From a psychodynamic perspective, I am always listening to clients in therapeutic conversations with certain key questions in my mind. Who is talking (with whose voice) to whom? And about what, or whom, are they talking? I may listen, for example, to a mother talking about her child as a disguised complaint about her husband and the marriage. If a child is threatening to run away all the time, is this a kind of sympathetic magic, the enactment of the wish that the mother leave the impossible bullying father? Where the father talks endlessly of his sons refusal to communicate with him, is he saying he feels his wife to be cold and rejecting? Some of these questions can be explored in meetings with the parents alone, when they may feel freer to open up about their own difficulties as part of an exploration of their theories about the origins of their childs problems. But it is in an attitude towards the area of puzzling child behaviour or symptomatology that the child psychotherapist may have a specific contribution to make within primary mental health work. I am thinking here of those cases where the childs presenting difficulty seems to be a genuine and personal construction of the child alone, and is not an understandable reaction to parental difficulties, and where the problem does not seem to serve a clear function in the family.

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Case example: Susan

Susan is 17 and is failing at school, despite major academic success in the past. She no longer completes homework on time and her grades have tumbled. She feels depressed. Her parents and school are bewildered, as is Susan, who sees the once clearly identified dream of her identified chosen future career as now hopeless and unrealisable. I speak to the parents to eliminate the possibility that they are applying pressures to their daughter but I am convinced by their loving and supportive concern that this is not the case. They are happy for their daughter to take a break from school and return to study at a later date if she would like to. But Susan is paralysed, unable to leave or stay. I meet Susan on her own at her request and ask her, through her tears, to assume, for a moment, that this is not the incipient madness she fears, but is the logical self-protective action of a person who feels, somewhere, hurt and frightened, or is perhaps troubled by her own excitement. In what kind of situation, I ask her, might this apparently self-defeating behaviour be logical and appropriate? When might it make sense? She does not, of course, answer but I believe that the question has conveyed my certain conviction that this seemingly incomprehensible difficulty is in principle understandable, even if it is not yet, or perhaps never, fully understood. She is visibly less anxious and we joke as she leaves that perhaps she could write a short story in which the heroine struggles with exactly this problem. She might also, I suggest, pay close attention to whatever she finds herself dreaming. At a further session, Susan tells me she has started to work at school again, although she is not sure what has led to the change. During the intervening weeks, she has found herself thinking about her fears of success, with the possibility this might mean she will be alone and unhappy. She has thought a lot about loyalty and betrayal, without ever being able to link these thoughts to any beliefs about her parents or siblings, although she has found herself wondering, at moments, if she is frightened about standing apart from her friends. While she is talking, I try to remember who it was that said: whenever we approach the unconscious it is always closing time, when Susan suddenly tells me that she has had a problem with her composition of the short story we joked about last time. Apparently, the explanation for the heroines predicament, which only comes to light in the last sentence of the last page, changes every time she goes to write it. Kafka again: Usually the one you are looking for lives next door. This isnt easy to explain, you must simply accept it as a fact. It is so deeply founded that there is nothing you can do about it, even if you should make an effort to. The reason is that you know nothing of this neighbour you are looking for. That is, you know neither that you are looking for him nor that he lives next door, in which case he very certainly lives next door. You may of course know this as a general fact of your experience; only such knowledge doesnt matter in the least, even if you expressly keep it forever in mind.

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References
Bateson, G. (1972) The cybernetics of self: a theory of alcoholism, in Steps to an Ecology of Mind, ed. G. Bateson, Ballantine, New York. Durrant, M. & Coles, D. (1991) The Michael White approach, in Family Therapy Approaches with Adolescent Substance Abusers, eds T. C. Todd & M. D. Selekman, Allyn & Bacon, Needham Heights, MA. Ecker, B. & Hully, L. (1996) Depth Oriented Brief Therapy, Jossey-Bass, San Francisco. Epston, D. (1989) The Collected Papers of David Epston, Dulwich Centre Publications, Adelaide, South Australia. Kafka, Franz (1948) The Diaries of Franz Kafka 19101923, ed. Max Brod, Minerva, London. Rank, Otto (1927) Parental attitudes and the childs reactions, in A Psychology of Difference The American Lectures of Otto Rank, ed. Robert Kramer (1996), Princeton University Press, Princeton, NJ. Selekman, Matthew D. (1997) Solution-focused Therapy with Children, The Guilford Press, New York. Talmon, Moshe (1990) Single Session Therapy, Jossey-Bass Publishers, San Francisco. Winnicott, D. W. (1971) Therapeutic Consultations in Child Psychiatry, The Hogarth Press and the Institute of Psychoanalysis, London.
Paul van Heeswyk is Head of Child and Adolescent Psychotherapy in Bexley, Bromley and Greenwich CAMHS. Address: Highpoint House, Memorial Hospital, Shooters Hill, London SE18 3RZ, UK. [email: paul.van-heeswyk@oxleas.nhs.uk]